Sterilization expectations from The Joint Commission

By: July 29th, 2009 Email This Post Print This Post

There’s been quite a bit of controversy surrounding The Joint Commissions’ recent position on sterilization requirements. In its attempt to solidify some survey standards, it seems The Joint has issued some confusion instead.

Many healthcare workers familiar with the sterilization process question whether The Joint Commission consulted many expert sources, since some of the terminology in the position statement seems dated.

Some particular problems stem from The Joint Commissions’ stance on flashing, a sterilization process that does not utilize a full cycle. Here are some of the main concerns:

  • There is no mention of flash sterilizing implants, which have been restricted in the past.
  • The statement says surveyors will look for instances where facilities use a “high percentage of steam sterilization using less than a full sterilization cycle, as well as exclusive use of this process for certain types of instruments.” This statement is vague, as it does not define an acceptable percentage.
  • There is no mention of requirements for event-related sterilization vs. time-related sterilization.

The good news is the Joint Commission did mention what surveyors will be looking for. Based on those statements it seems that despite some of the above confusion, a surveyor will deem it acceptable if your facility follows the manufacturers instructions for each instrument, the sterilizer, and the wrapping (surveyors will be looking for proof of these instructions), and show that you limit the incidence of flash sterilization.

For more detailed sterilization guidance, you can always refer to the CDC/HICPAC guidelines, ANSI/AAMI ST79, or read my previous steam sterilization post. You can also visit the Tools section for a free downloadable Sterilization Line Listing Log – one of the documents surveyors will be looking for.

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Comments

By Susan K Foster on July 29th, 2009 at 8:50 am

Thanks so much for the toolkit! It will be very useful!

By Dee Henderson Dunn on September 9th, 2010 at 5:00 pm

Is anyone willing to share how they have defined “acceptable reasons” for why an item was flashed? We are changing our sterilization logs to reflect more acceptable reasons for why an item was flashed and would like to know what others are capturing. for example:
urgent and unpredicted event (emergency surgery), unique one-of-a-kind item

 

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